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NEUROLOGICAL: CRITICOOL: OPERATING PROCEDURE

DOCUMENT TYPE: PROCEDURESite Applicability

Management of Hypoxic Ischemic Encephalopathy (HIE) occurs in the NICU

Guideline StatementsThe Physician orders CritiCool™ as a primary route of therapeutic hypothermia or therapeutic normothermia for the treatment of infants with Hypoxic Ischemic Encephalopathy (HIE).

Procedure Procedure Table of Contents:

Pg. 1: PreparationPg. 4: ApplicationPg. 6: X-RayPg. 7: Re-WarmingPg. 8: MRIPg. 9: Post ProcedurePg. 9: Documentation

Gather Equipment: CritiCool™ with CliniLogger (with or without splitter attached) Hydrocolloid dressing Waterproof tape Lubricating jelly (water soluble) Rectal temperature probe #9 Fr Skin temperature sensor Thermowrap jacket Sterile water (6 litres) If using CritiCool™ with splitter: Philips monitor temperature cable

Preparation Note1. Obtain CritiCool™ device with water hoses

and clinilogger attached Clinilogger should be plugged in at the back of the

CritiCool™

2. Bring CritiCool™ and appropriately sized Thermowrap jacket to bedside

3. Plug in CritiCool™ and splitter power

See table above

C-06-12-60207 Published Date: 20-Jun-2017 of 10 Review Date: 20-Jun-2020 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.


DOCUMENT TYPE: PROCEDURE

cables

4. Fill the reservoir with 6 litres of sterile water

Do not use tap water Do not over fill Fill to level between two red markings

5. Plug Green sensor into Surface socket of CritiCool™ (if not already plugged in)

A).If not using splitter: Plug GRAY sensor into Core

socket of CritiCool™B).If using splitter:

Plug GRAY sensor into Core socket on splitter

Plug temperature monitoring cable into Philips monitor and set temperature limits to 33.0 and 37.5 degrees Celsius

Change Philips monitor screen to CritiCool™ mode

Criticool Splitter:

6. Position the Thermowrap in the bed so the water tubing connectors are positioned above the infants head.

Connect water tubes to the Thermowrap.

The tubing/clamps need to lay flat on the mattress to prevent kinking

Put the tubing through the slot at the head of the bed, not through the side ports to prevent kinking

Check clamps are open The Thermowrap will automatically fill once the rectal

probe is in place

7. Turn on Machine will alarm for self-test and

errors

8. Select “COOLING” for both Therapeutic Hypothermia and Therapeutic Normothermia by pressing ok

The water level may fall below the two red lines Do not top up water By using the “cooling” mode the variance of

temperature will be +/- 0.2 ºC of the set point

9. Perform safety check prior to use to ensure settings are correct

1. Press Menu2. Press Settings3. Press Enter

Clinilogger should be plugged in at the back of the CritiCool™


GRAY sensor

Temperature monitoring cable



4. Ensure values are entered as below:Patient *NeonatalAdult SP *33.0Delta T *0.45. Press Exit

The ‘COOLING’ Mode set temperature is 33.5ºC

10. For Therapeutic Hypothermia pre-set temperature is 33.5ºC

11. For Therapeutic Normothermia set temperature on CritiCool™ to 36.7ºC by using the up and down arrows

Check hourly that the set point is at the desired temperature (33.5 ºC for therapeutic hypothermia and 36.7 ºC for therapeutic normothermia)

12. Place CritiCool™ in ‘standby’ until infant arrives

Select ‘menu’ Scroll down and select ‘standby’ Select ‘enter’




Application Note13. Lay infant, wearing only a diaper, supine

on Thermowrap Align cut outs for arms with the axilla Align lower flaps with the upper thighs Do not wrap infant yet

Infant must be repositioned according to skin risk assessment

Prone position is contra-indicated

14. Obtain rectal temperature probe (#9 Fr) and measure 5 cm from tip and mark with pen

15. Lubricate rectal temperature probe and insert 5cm into rectum. Connect to Gray sensor

Use water soluble jelly Secure at the rectum with hydrocolloid dressing

and waterproof tape

16. Secure skin temperature sensor and connect to Green sensor

Use skin temperature sensor Choose a site as close to core of infant as possible This sensor must not come in contact with the

Thermowrap (e.g. upper chest, thigh) Clean site with water, dry skin and apply sensor

17. Take CritiCool™ off ‘standby’ mode Select ‘Menu’ Select ‘Operate’

Check temperature is set at (33.5 ºC for Therapeutic Hypothermia and 36.7 ºC for Therapeutic Normothermia)

18. Monitor as the Thermowrap automatically fills

Correct any alarm conditions identified Correct any kinking or leaks Allow Thermowrap to fill with water prior to

wrapping around the infant

19. Once Thermowrap is filled, wrap around the infant’s torso and upper thighs

*Do not use safety pins on any part of the thermowrap: extra securing tapes are available if needed*

20. Fold Thermowrap as needed to expose areas of infant

Ensure there is no kinking obstructing water flow in the system

Folding the Thermowrap may be done to expose certain areas of the infant (e.g. umbilical lines)

If Thermowrap is kinked and obstructing water flow alarm ‘Check Water Connections’ (see troubleshooting guide)

21. Check the radiant warmer is off




22. Assess skin integrity Utilize Skin Risk Assessment and provide corresponding care activities based on risk identified

Cooled infants are at increased risk for fat necrosis and require frequent position changes and skin assessment

Monitor carefully for moisture between the skin and Thermowrap (moisture can contribute to increased risk)

If mildly soiled clean Thermowrap with water and dry If extremely soiled or punctured, change Thermowrap

23. Parents may hold infant with Thermowrap in place to maintain cooling




X-ray Note24. Loosen the wrap and slip the x-ray plate

between the infant and wrap The Thermowrap shows shadows on any x-ray




Re-warming Notes25. To re-warm:

Press menu key Scroll to “MODE SELECT” Press enter Select “CONTROLLED REWARM (for

slow rewarming)” Press “OK” Machine makes audible tone Message “Switching to Re-Warming”

While the screen is visible rewarming has not started (see picture on right)

Check rectal probe is correctly placed Press “Operate”. Ensure set

temperature is 36.5 Screen will read “NEONATAL

REWARMING”

CritiCool™ will increase the Set Point Temperature by 0.40C every 60 minutes

Re-warming to 36.50C will take 7-8 hours

26. Continue therapy on the CritiCool™ device for 24 hours after the infant’s temperature has reached 36.50C

Once the infant’s temperature reaches 36.50C, the mode display will stay in “NEONATAL REWARMING”.




MRI Note27. Put CritiCool™ on standby Refer to MRI checklist

The Thermowrap will automatically drain

28. Allow the Thermowrap to drain and clamp water tubes

Draining takes approximately 5 minutes

29. Disconnect water tubes from Thermowrap

30. Remove skin probe from infant Leave connected to CritiCool™ for reapplication after MRI

31. Without splitter: Disconnect rectal probe from GRAY CritiCool™ core cable and connect to Philips monitor temperature cable and plug into X2 transport monitor

32. With splitter: Disconnect rectal probe from GRAY CritiCool™ core cable on splitter and connect to Philips monitor temperature cable

33. Once infant is transported to MRI remove rectal probe

Probes are not MRI compatible Refer to MRI checklist for thermomanagement

34. Unwrap infant from Thermowrap and transfer care to MRI team

35. Upon return to NICU, reconnect water tubes to Thermowrap

36. Unclamp water tubes

37. Take CritiCool™ off ‘standby’ mode Select ‘Menu’ Select ‘Operate’

38. Verify correct mode: For infants being actively cooled

place back in ‘COOLING’ mode For infants who have completed

rewarming place back in ‘NEONATAL REWARMING’ mode.

CritiCool™ will start from the infants current core temperature (i.e. if putting CritiCool™ back in the re-warm mode after MRI the infant will be warmed from its current temperature to reach the set temperature)

Infants must complete 24 hours in ‘NEONATAL REWARMING’ mode after they have been rewarmed.




Post Procedure Note39. Turn the CritiCool™ Device to ‘standby’ Wait while the water drains back into the CritiCool™

Disconnecting the unit prematurely will cause water leakage

40. Close the clamps on the Thermowrap

41. Turn off CritiCool™

42. Disconnect the water tubes from the Thermowrap.

43. Unwrap the infant and discard Thermowrap

Thermowraps are individual use items and are discarded after each infant

44. Assess infant’s skin after removal of Thermowrap

A pattern resembling the Thermowrap may appear for a short period of time on the infant’s skin

45. Remove the rectal and skin temperature probes and disconnect from the CritiCool™ unit

Gray sensor and Green sensor are not disposable

46. Save stored data from CliniLogger Remove CliniLogger and ensure labelled with patient label

Leave in CNL office at CRN desk

47. Return the CritiCool™ unit, with all cables and tubing’s connected, to the aides room

The grey and green cables and water hoses are NOT disposable

Aides will empty and clean CritiCool™ machine

DocumentationNursing Flowsheet:

Hourly skin and rectal temperature Hourly CritiCool™ ‘set point’ Skin integrity Interruptions to cooling

Physician’s Orders: Date and time cooling/ re-warming started

Documentation Nursing FlowsheetBedside Information Tool (BIT)Troubleshooting GuidelinePhysician’s Orders – Therapeutic Normothermia AdmissionPhysician’s Orders – Therapeutic Hypothermia Admission

References CritiCool™ Operating Manual




Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN16-May-2019

C-06-12-60207 Neurological: Criticool: Operating Procedure

Updated by: Neonatal Critical Care Committee Temperature for normothermia adjusted from 36.0 to 36.7

04-May-2020

“ Updated by Neonatal Program Senior Practice Leader Rationale in Step 7 Page 2 removed due to software update

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.

C-06-12-60207 Published Date: 20-Jun-2017 of 10 Review Date: 20-Jun-2020

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.

word: neurological criticool operating...

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